I.

THYROIDECTOMY CARE
1. O2 therapy, suction secretions.
2. Monitor for signs of bleeding and excessive edema
3. Elevate HOB 30. Support head and neck to avoid tension on sutures
4. Check dressing frequently, check behind the neck, shoulders for bleeding.
5. Assess for signs of respiratory distress, hoarseness (laryngeal edema or damage.
6. Keep tracheostomy set in patients room for emergency use.
7. Administer food and fluid with care (dysphagia is common).
8. Encourage client to gradually ROM of neck.
9. Teach about medications, frequent follow-up. If thyroidectomy - life long replacement
of medication (T5, T4). Subtotal thyroidectomy - careful monitoring of return of thyroid
function.
10. THINK BOW TIE:
B = Bleeding
O = open airway
W = whisper
T = trach set
I = incision
E = emergency
11. Be alert for post op complications
A. Tetany: Due to hypocalcemia caused by accidental removal of parathyroid gland.
Assess for numbness, tingling, or muscle twitching. Monitor for Chvosteks sign and
Trousseaus sign. Give calcium gluconate IV slowly.
B. Hemorrhage: Monitor for hypotension, tachycardia, other signs of hypovolemia.
Irregular breathing, swelling, choking - possible hemorrhage and tracheal compression.
Early signs of hemorrhage: Repeated clearing of throat, difficulty swallowing.
C. Thyroid storm: Life threatening. Sudden increased release of thyroid hormone. Assess
for fever, tachycardia, ing restlessness, agitation, and delirium.
MYXEDEMA - Hypothyroidism - NOT ENOUGH ENERGY/ CRETINISM
A. Occurs when there is an insufficient amount of thyroid hormone (TH) being
secreted by the thyroid gland causing a ed metabolic rate, decreased heat
production. CRETINISM: Hypothyroidism present at birth
B. Hyposecretion of thyroid hormone results in overall decrease in metabolism.
C. ETIOLOGY: An autoimmune disorder (Hashimotos thyroidism)causing
destruction of the thyroid gland. External irradiation of the thyroid gland,
infections, iodine deficiency. Lithium therapy.
1. Hashimotos thyroidism: The immune system attacks the thyroid gland.
D. S/S: Fatigue, weight gain, dry flaky skin, cold intolerance, course brittle hair,
hypothermia, lethargy, diminished reflexes, periorbital edema, bradycardia,
dysrhythmias, infertility, C/O cold hands and feet, hair loss, prolonged DTR-ed,
enlarged heart, muscle aches or weakness, constipation & ed libido.
E. CRETINISM: Hypothyroidism that is present at birth. Is very dangerous and

can lead to slowed mental and physical development if undetected.

1. State of severe hypothyroidism in infants. Infants do not produce normal
amounts of thyroid hormone.
2. Their skeletal maturation and CNS development are altered resulting in
retardation of physical growth, mental growth, or both.
F. TREATMENT/NURSING INTERVENTIONS
1. Diet: High fiber, high protein, low calorie, ^ed fluid intake (2000 mL/day)
2. Because of altered metabolism, patients do not tolerate barbiturates or
sedatives. Therefore CNS depressants are contraindicated.
3. Give medication in the AM one hour before food or 2 hours after.
4. Do not give beta blockers to asthmatics or diabetics - hides symptoms of
hypoglycemia.
5. Start thyroid medications at lowest dose and graduate to larger doses.
A. Dosage is increased every 2-3 weeks until the desired response is achieved.
Advise patient that treatment is lifelong requiring constant monitoring by MD. If
thyroid drug is discontinued, it must be tapered.
B. Teach patient S/S of hyperthyroidism which can occur with overmedication.
6. Caution patient against electric blankets, extra clothing because of
vasodilation.
G. MYXEDEMA COMA: Life threatening crisis state of hypothyroidism.
1. Myxedema coma/crisis occurs as a result of long-standing or untreated
hypothyroidism who experience significant stress as infection, medication,
exposure to a cold environment or systemic disease.
A. Can be precipitated by infection, drugs - especially opioids, tranquilizers, and
barbiturates.
2. Myxedema is an accumulation of hydrophilic mucopolysaccharides in the
dermis and other tissues. This causes characteristic signs of hypothyroidism:
puffiness, periorbital edema, and mask-like affect. Thinning eyebrows.
3. Virtually every organ system is affected.
4. S/S: Lethargy, stupor, ed oxygen & blood flow to the brain occurs.
Bradycardia & ed contractility = low cardiac output. ed renal function.
Unresponsiveness, edema, hypoventilation, hyponatremia, hypotension,
hypothermia, Progressive stupor. Periorbital edema, non-pitting edema, puffy
face and tongue. Significantly depressed respirations.
5. TREATMENT
A. The overall treatment is restoration of euthyroid state (having a normal thyroid
gland as rapidly and safely as possible with hormone replacement. Levothyroxine
(Synthroid) is the drug of choice - give slowly
B. Maintain airway patency.
C. Maintain circulation with IV therapy and ECG monitoring.
D. Monitor V/S, ABG, I & O, patient temperature.
E. Keep patient warm
F. Administer corticosteroids as ordered. Assess for infections.
G. Patient at risk for CAD - monitor
H. Assess for skin alterations - apply lotion, etc.

I. With rapid administration of thyroid hormone, plasma T4 levels may initiate

adrenal insufficiency, hence steroid therapy may be ordered.
1. GRAVES DISEASE - Hyperthyroidism - TOO MUCH ENERGY
A. Increased synthesis of thyroid hormone from overactivity.
B. Excessive secretion of thyroid hormone
1. Leads to increased basal metabolic rate (BMR).
2. Increased cardiovascular function, ^ed GI function, ^ed neuromuscular
function, weight loss, and heat intolerance.
3. Thyroid hormone affects metabolism of fats, carbohydrates, and proteins.
4. Calcitonin inhibits mobilization of calcium from bone and s blood calcium
levels
C. An autoimmune disorder.
D. Etiology: Excess secretion of TSH from pituitary gland. Thyroiditis, tumor,
goiter. Physiological or psychological stress, infections,
F. S/S: Nervousness, weight loss despite increased appetite, sweaty/hot (heat
intolerance), exophthalmus (no cure for this), hyperactivity (cant sit still), ^ed
appetite, B/P ed, flushed smooth skin, oliogomenorrhea or amenorrhea,
palpitations, insomnia. ALL V/S ARE ^ed - think of patient as being hyperactive.
G. DIAGNOSIS: Serum T3 and T4 are increased. Radio-iodine uptake is
increased. Thyroid scan shows enlarged thyroid gland or nodules.
H. TREATMENT/NURSING INTERVENTIONS
1. Monitor V/S & I & O - determine presence of thyroid storm.
2. Lifelong antithyroid medication.
3. Surgical removal of thyroid.
A. Radioactive iodine 131
1. The thyroid gland absorbs the I-131 which destroys some of the thyroid cells
over a period of 6 to 8 weeks. RULE OUT PREGNANCY FIRST.
2. Advise patient against close contact with other people, avoid kissing for 24hours.
3. Test females for pregnancy. Pregnancy should be delayed 12 months.
4. Advise patient to drink with straw
B. Thyroidectomy or partial thyroidectomy
1. Instruct patient to hold hands behind neck when coughing, sitting, turning, or
getting up/back into bed to reduce post-op pain and decrease tension on suture
line.
2. Position semi-fowlers with head and neck supported. Ice collar to wound to
prevent edema.
3. Monitor for hemorrhage, edema, exudates over upper chest, upper back,
shoulders, back of neck.
4. Promote patent airway - keep HOB elevated 30 degrees. Keep sterile oral
suction and emergency tracheotomy tray within reach. Avoid hyperextension of
the neck
5. Keep phone, personal items, call bell, remote control within reach.
6. Diet: Increase calories

7. Assess for laryngeal nerve damage: assess for hoarseness. Could lead to
vocal cord paralysis. If there is paralysis of both cords, airway obstruction will
occur requiring immediate trach. Bilateral nerve damage = breathing difficulties
and aphonia (inability to speak)
8. Instruct patient to report any signs of pressure on neck.
9. Give eye care for exophthalmus: Moisten eyes frequently with artificial tears to
prevent irritation corneal infection. Protect eyes from photophobia with glasses.
Sleep with HOB elevated to minimize pressure on optic nerve and eye patches to
protect eyes during sleep if lids do not close. Soothe eyes with cool compresses.
10. Prevent tetany by identifying hypocalcemia - numbness or tingling of toes,
extremities, and lips, muscle twitches, positive Chvosteks & Trousseau.
A. RULE OF NINES
Head= 9% Arms = 18%( 9% each) Back= 18% Legs= 36%( 18% each)
Genitalia= 1%
REVIEW - OB/PEDS 11/00
1. What is a non stressed test?
- demonstrates fetus's ability to respond to its environment
- When the fetus has adequate oxygenation and an intact CNS there will be
accelerations of the FHR with fetal movement.
1A. Interpretations of NST results
REACTIVE TEST: Shows at lest 2 accelerations of FHR with movement of 15
beats
per minute, lasting 15 seconds or more, over 20 minutes.
NONREACTIVE TEST: The reactive criteria are not met. Accelerations are not
present, indicating that the fetus is sick or asleep.
UNSATISFACTOR TEST: An unsatisfactory NST has data that cannot be
interpreted
or inadequate fetal activity.
Most NST require 2 accelerations of FHR in 20 minutes.
2. Fetal monitoring (how is it done)
- Electric fetal monitoring (EMF) provides visual assessment of fetal heart
rate.
- Internal monitoring - requires an internal spiral electrode and membranes
must be ruptured.
- External monitoring is usually accomplished by ultrasound.
- Normal fetal heart rate is 120 - 160 BPM
3. Periodic changes

- Transient decelerations or accelerations of the FHR from the baseline. They

usually occur in response to uterine contractions and fetal movement.
Accelerations
- Sign of fetal well being (transient accelerations) when fetus moves its
heart rate increases.
Decelerations
- Decreases in FHR from normal baseline into three categories:
1. Early decelerations: Head compression = cerebral blood flow decreased =
central vagal stimulation. The onset of decel occurs before the onset of
uterine contraction. (Considered benign)
2. Late deceleration: Caused by uteroplacental insufficiency resulting from
decreased blood flow and oxygen transfer to the fetus through the
intervillous spaces during uterine contractions. (Non reassuring sign, but
doesn't necessarily require immediate delivery).
3. Variable decelerations: Occurs if the umbilical cord becomes compressed,
thus reducing blood flow between the placenta and fetus (requires further
assessment immediately).

4. Preterm labor - drugs we use to treat this

- labor that occurs between 20 and 37 weeks of pregnancy
- tocolysis - use of medication to stop labor
- tocolytic - beta adrenergic agonists (beta mimetics)
- MgSO4, prostaglandin synthetase inhibitors, calcium channel blockers.
- (beta mimetics) = Ritodrine, Terbutaline, MgSO4
- Although tocolytic drugs suppress uterine contractions and allow pregnancy
to continue the beta mimetics cause maternal side effects - most serious is
pulmonary edema.
- Nifedepine - calcium channel blocker (decreases smooth muscle contractions)
Do not use with MgSO4.
5. Primary nursing focus with patient on tocolytic therapy
monitor fetal heart tones
assess for contractions (frequency)
Dilation?
Monitor patients vital signs,
Assess for I & O
DTR (especially on MgSO4)
6. Most common cause of preterm labor is?
Beta strept +
7. Preterm labor, what is used for fetal lung development?
Betamethasone

- glucocorticoid
- Induces pulmonary maturation and decreases the incidence of RDS in preterm
infants.
- Most effective when given 24 hours of dose
- Careful with use in mec deliveries, mask of infections and suppresses
immune system.
8. What is first nursing action after rupture of membranes?
Assess for fetal heart tones
9. What do we do for a prolapsed cord? (s/s also)
- relieve pressure on cord manually
- continuously monitor FHR, watch for changes in FHR pattern
- assist mom into knee-chest position
- administer oxygen
- FHR may show variable decelerations (s/s)
10. PROM - what do you not do?
No vaginal exam until sterile speculum is asked for by MD or CNM
11. Problems with induction of Pitocin
- discontinue Pitocin with
- contractions more frequent than q 2 minutes
- contractions duration exceeds 90 seconds
- uterus does not relax between contractions
12. Not a good candidate for induction
- CPD
- Predisposition to uterine rupture
- Malpresentation or malposition of the fetus, cord prolapse
- Preterm infant
- Rigid, unripe cervix, total placenta previa
- Presence of fetal distress
13. Good candidate for VBAC/ and who would not be?
Good
Not Good
14. Common complications with multiple pregnancies (twins etc.)
- SOB
- Dyspnea on exertion
- Backaches
- Pedal edema
- UTI
- PIH

- Preterm labor
- Placenta previa
- Abruptio placentae
- Prolapsed cord
- Hemorrhage immediately after or in the first few hours after birth
DURING DELIVERY
- large bore IV access
- anesthesia
- crossmatched blood readily available
- electronic fetal monitoring
- probable delivery by c/s
- labor may progress very slowly or very quickly
15. Pregnant diabetic (problems with baby, and what does glucose and
surfactant do?)
- get blood sugars
- give insulin if needed (give Regular)
- order ultra sound (check size of baby if possible)
- monitor External FHT
- IV
- Monitor for 20 minutes
- Look for accelerations with movement, no decels with contractions and beat
to beat variability
- (remember that the placenta creates hormone that gets rid of extra diabetic
- These moms have higher metabolic needs and may have BS out of control.
- Check blood glucose in labor at q 1 hour
- Most likely will need insulin drip in labor
16. What are signs and symptoms of a ruptured uterus (what is nursing action)?
FHT decreases rapidly
Complains of intense abdominal pain
Tetanic contractions
Nursing actions:
* if on pitocin stop it immediately and call for help
- oxygen 8-10 l by mask get patient on left side
- check vital signs for reasons for drop
- type and cross units of blood
- get garden hose IV line in and give universal blood if appropriate
- DO SOP's according to hospital policy.
17. Know labor dystocia (hyper and hypo uterine dystocia)
18. Know most common fetal mal-presentation?
Most common presentation is cephalic
Most common mal-presentation is face presentation (?) check this one out

yourself (page 451) I may be wrong???

19. Difference between Abrupto and Previa?
Placenta Previa: Abnormal implantation of the placenta in the lower uterine
segment. Classification of type is based on proximity to the cervical os:
total = completely covers the os. Partial = covers a portion of the os.
Marginal = is close proximity to the os.
- no pain
- Do not check cervix (you can poke through placenta and she will bleed out).
- Sterile spec exam by provider (looking for red over cervical OS
- NURSING ACTION
- Give her IVF
- Labs (t & c)
- Oxygen, baby and mom are loosing blood
- Sign consent
- Social services
- Vital signs also very important
- Prepare for OR delivery
- Painless vaginal bleeding after seventh month
- Quiet and sneaky onset
- No uterine tenderness
- Uterine tone soft and relaxed
- Usually present fetal heart tones
Abrupto: partial or total premature separation of a normally implanted
placenta.
- Can have vaginal bleeding or not.
- Extreme tenderness of abdominal area
- Rigid, boardlike abdomen
- Increase in size of abdomen.
- Sudden and stormy onset
- Severe and steady pain
- Present uterine tenderness
- Uterine contour may be enlarged and change shape
- Fetal heart tones may be present or absent
20. When is Vacuum extraction used and the nursing use of one?
- It is used for the elective shortening of the second stage of labor and
relieving the woman of the pushing effort or when anesthesia or fatigue
interferes with the woman's ability to push effectively.
NURSE
- keep woman informed about what is happening
- FHR should be auscultated every 5 minutes or more frequently
- Inform parents about the Caput on the baby's heat will disappear in a few
hours
- Asses the newborn for
- Cerebral trauma

- Soft tissue necrosis.

Following thyroidectomy,
--weakness and hoarseness of the voice can occur as a result of trauma from the
surgery.
--If this develops, the client should be reassured that the problem will subside in
a few days.
--Unnecessary talking should be discouraged.

DKA (Diabetic ketoacidosis) tretment

--Lack (absolute or relative) of insulin is the primary cause of DKA.
--Treatment consists of insulin administration (regular insulin), IV fluid
administration (normal saline initially), and potassium replacement, followed by
correcting acidosis.

Hyperglycemic hyperosmolar nonketotic syndrome

-- occurs in clients with type 2 diabetes mellitus.
--The onset of symptoms may be gradual.
--The symptoms may include polyuria, polydipsia, dehydration, mental status
alterations, weight loss, and weakness

To know the normal systolic for a child 1-7 years old

Age +90. Example 3yo child = 93 systolic.
Here is another. Do not mix zosyn and gentamycin IV wait at least an hour to
decrease the risk of gentamycin inactivation.

Coal tar
--is used to treat psoriasis and other chronic disorders of the skin.
--Coal tar suppresses DNA synthesis, mitotic activity, and cell proliferation.
--Coal tar has an unpleasant odor, frequently stains the skin and hair, and can
cause phototoxicity.
--Systemic toxicity does not occur.

Mafenide acetate

--is bacteriostatic for gram-negative and gram-positive organisms and is used to

treat burns to reduce bacteria present in avascular tissues.

--The client should be informed that the medication will cause local discomfort
and burning.
-- is a carbonic anhydrase inhibitor and can suppress renal excretion of acid,
thereby causing acidosis.
-- Clients receiving this treatment should be monitored for signs of an acid-base
imbalance (hyperventilation).
--If this occurs, the medication should be discontinued for 1 to 2 days.

Sodium hypochlorite
--is a solution used for irrigating and cleaning necrotic or purulent wounds.
--It cannot be used to pack purulent wounds because the solution is inactivated
by copious pus.
--The solution should not come into contact with healing or normal tissue and
should be rinsed off immediately following irrigation.
--The solution loses its potency during storage, so fresh solution should be
prepared frequently.

Isotretinoin (Accutane)
-- can elevate triglyceride levels.
--Blood triglyceride levels should be measured before treatment and periodically
thereafter until the effect on the triglycerides has been evaluated.

Lindane (treatment for scabies)

--is applied in a thin layer to the body below the head. No more than 30 g (1 oz)
should be used.
--The medication is removed by washing 8 to 12 hours later.
--In most cases, only one application is required.

Topical corticosteroids can be absorbed into the systemic circulation.

Absorption is higher from regions where the skin is especially permeable (scalp,
axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where
permeability is poor (back, palms, soles).

The normal platelet count is 150,000 to 450,000/mm3. When the platelets

are lower than 50,000 /mm3, any small trauma can lead to episodes of prolonged
bleeding. The normal white blood cell count is 5,000 to 10,000/mm3. When the
white blood cell count drops, neutropenic precautions need to be implemented.
The normal clotting time is 8 to 15 minutes. The normal ammonia value is 15 to
45 mcg/dL.

Crestor=Rhabdomyolysis (muscle Weakness)

PH of stomach acid lessthan 4 is good
Drug catagory X=risk for fetus
Colchicine=antigoout medication
Lasix=K wasting=increasebananas and oranges
heart failure infant=increased resp rate
PIH=periorbital and facial edema

Thallium stress test=allergic to Iodine should be asked

Warm insulin bottle is good for 1 month only
Causes of abdominal distention
The 6 F's
Flatus----Feces----fetus----Fluid---Fat----Fatal(Malignant) neoplasm

1. If mishap occured like patient fell, write up an incident report and

NEVER chart in the medical records that an incident report was filed.
2. If px died and was found on drivers license to be an organ donor, still have to
get permission from next of kin before taking organs. order of priority is
1st ask the spouse, if none...2nd ask son or daughter, 3rd mother, 4th adult
brother or sister, 5th Legal Guardian.
3. For airborne diseases measles, varicella, TB....use a particulate filter mask not
a surgical mask
4. For droplet isolation patients, everyone must wear a mask if they are going
wtihin 3 feet of the patient.

5. PKU, baby born without ability to utilize essential amino acid called
phenylalanine so don't give diet soda bec it contains nutrisweet, nutrisweet
contains phenylalanine.

The rules of Management:

Do not delegate assessment teaching or evaluation
Delegate care for stable pt's with expected outcomes
Delegate tasks that involve standard unchanging proceedures
Treatment for Monnucleosis= Bedrest
Amphojel=S/E Constipation
Diagnostic test for cirrhosis=Liver biopsy
Contaminated shellfish=Hep A
Murphy's sign=On deep inspiration pain is elicited and breathing stops
Abd Ultrasound=Dx for cholecystitis
Pancreatitis=avoid Caffine and alcohol
Pancreatitis= increased Amylase and lipase and glucose and decreased serum
CA levels
After liver biopsy=place client on the right side laying position with the bed flat
Tensilon test=Mysthesia gravis
Xerostomia=dry mouth
dysgeusia=siminish sense of taste
Dilantin can cause decreased HR hypotension
Pyridium=Causes the urine to be red or orange
Club soda=sodium chloride
Gallbladder is on the right
Guthrie blood test is a test for PKU
Tetracycline can cause staining of the teeth
Test for seizures=EEG
Vit C may decrease warfarin effects
Vit E may increase warfarin effects

Dumping syndrome=moderate fat low carbs diet

Colostomy begins to function 3-6 days after surgery
Viagra=NO Nitroglycerin
250ml=I unit of PRBC (packed red blood cells)

Calcium and aluminum based antacids cause constipation

Magnesium based cause diarrhea
Mydriatics (big word big pupil) treats cataracts...I always picture a cat acting
( CAT ar ACTS) in a big whole ...it sound stupid I know!
Miotics (small word small pupil) treats glaucoma
Maternal hypotension after an epidural anethesia: STOP
S= stop pitocin if infusing
T= Turn on left side
O=Oxygen
P= Push fluids (if hypovolemia)

HELLP= hemolysis, elevated liver enzymes, and low platelet

count=elevated hepatic enzymes
Chronic renal failure patients should avoid astringent cleansing pads
Clients with a central venous catheter receiving TPN has an air embolus the
nurse should clamp the catheter immediately and notify the physician.
Crackles in the lung fileds of the peritoneal dialysis client result from
overhydration or from insufficient fluid removal during dialysis. Intake grater than
the output of the peritoneal dialysis fluid would overhydrate the client, resulting in
lung crackles.
Colonoscopy=Left sims position
Normal platelets=150-400 cells mcg/l
No morphine=pancreatitis it causes spasms of oddis spincter.
Antineoplastic drugs=leukopenia=private room
Terminal patient=Palliative care
Tamoxifen increases the effects of Warfarin sodium
Tachycardia commonly occurs after giving Atropine
MMR Vaccine=Ask if Allergic to Gelatin, Eggs, or neomycin
Pneumocystis Carinii=Fungal
Vasopressin is a synthetic ADH Its used for treatment for Diabetes Insipidus
which results from deficient ADH
Glyburide=30 mins before breakfast
Pt with Thrombus in the leg on heparin=Strict bed rest
Ticlopidine (Ticlid) is used as a antiplatelet drug for Salicylate (Aspirin) sensitivity.
Protamine sulfate=comes from the sperm of salmon and other fish so don't use if
allergic to fish
Blood drawn for APTT on heparin is in 4 hours. Early would show high
Potassium is the most abundant cation in the ICP followed by
Magnesium.Because Potassium isn't stored it must be replaced every day.
Rh immunization for pregnant is:

Rh immunization of Rhogam is given when an Rh incompatibility occurs, which

only oocurs if the mother is Rh negative and the baby being born is Rh positive. It
does NOT occur when an Rh positive mom gives birth to an RH negative baby.
If some of the baby's red blood cells leak into RH-mom's system, then her body
may produce antibodies to the Rh D factor (a condition called sensitization).
These antibodies can cross the placenta and destroy the red blood cells in your
unborn baby or in the next Rh-positive baby you have.
***In most cases, the mom will not be exposed to the baby's blood until she gives
birth....... This usually means that first baby will NOT be affected.
****HOWEVER, large amounts of the baby's blood can leak into the mother
during delivery. If the mom is Rh negative, the next Rh-positive baby that she
could have may have problems if the Rh-negative mom has developed
antibodies
***** Occasionally, in the following situations, some of the baby's blood may leak
into the mom's blood system during pregnancy:
1. After amniocentesis or other invasive procedure
2. During a miscarriage or abortion
3. During an ectopic pregnancy
4. If the mom bleeds heavily during pregnancy.
Disseminated intravascular coagulation (DIC) and s/s
Disseminated intravascular coagulation (DIC) occurs when the body's clotting
mechanisms are activated throughout the body in response to an injury or a
disorder, instead of being isolated to the area of initial onset. Platelets circulating
throughout the body form small blood clots (thrombi) primarily in the area of the
capillaries. This eventually causes the clotting factors to be used up, and none
are left to form clots at the site of the injury. The presence of numerous small
clots precipitates the release of clot-dissolving mechanisms, and the end result is
generalized bleeding throughout the body.
This disorder can result in clots or, more often, in bleeding. The bleeding can be
severe.

Hemophilia refers to a group of bleeding disorders resulting from a

deficiency of specific coagulation proteins.
--The primary treatment is replacement of the missing clotting factor; additional
medications, such as those to relieve pain, may be prescribed depending on the
source of bleeding from the disorder.

-A child with hemophilia A will be at risk for joint bleeding after a fall. Factor VIII
will be prescribed intravenously (IV) to replace the missing clotting factor and
minimize the bleeding.

In severe cystic acne, isotretinoin (Accutane) is used to inhibit

inflammation.
--Adverse effects include elevated triglyceride levels, skin dryness, eye
discomfort such as dryness and burning, and cheilitis (lip inflammation).
--Close medical follow-up is required, and dry skin and cheilitis can be decreased
by the use of emollients and lip balms.
--Vitamin A supplements are stopped during this treatment.

Propylthiouracil is used to treat hyperthyroidism

---propylthiouracil (PTU) may convert the client from a hyperthyroid state to a
hypothyroid state. If this occurs, the dosage should be reduced.
--Temporary administration of thyroid hormone may be required.

--Levothyroxine (Synthroid) is a synthetic thyroid hormone that increases

cellular metabolism.
--Levothyroxine should be given in the morning in a single dose to prevent
insomnia and should be given at the same time each day to maintain an
adequate drug level.

Desmopressin acetate (DDAVP)

--is a synthetic form of antidiuretic hormone that causes increased reabsorption
of water, with a resultant decrease in urine output.
--The therapeutic response to DDAVP would be a decrease in serum osmolality,
because more fluid is retained, and an increase in urine osmolality, because less
fluid is excreted.
--Hypotension may be apparent with diabetes insipidus and blood pressure may
increase as extracellular fluid volume is restored.

Classic symptoms of hyperglycemia include

-polydipsia (Excessive thirst or drinking),
-polyuria
- polyphagia (excessive appetite for food)

Polydipsia and polyuria are classic symptoms of diabetes insipidus. The

urine is pale, and the specific gravity is low. Anorexia and weight loss occur.

Because of the hypermetabolic state, the client with hyperthyroidism

needs to be provided with

--an environment that is restful physically and mentally.

--Six full meals a day that are well balanced and high in calories are required
because of the accelerated metabolic rate.
--Foods that increase peristalsis, such as high-fiber foods, need to be avoided.
--These clients suffer from heat intolerance and require a cool environment.

Risk factors for DIC include:

Blood transfusion reaction
Cancer, including leukemia
Infection in the blood by bacteria or fungus
Pregnancy complications (such as retained placenta after delivery)
Recent surgery or anesthesia
Sepsis (an overwhelming infection)
Severe liver disease
Severe tissue injury (as in burns and head injury)
Signs & Symptoms Include:
Bleeding (possibly from multiple sites in the body),
Blood clots,
Drop in blood pressure, AND
Sudden bruising

therapeutic level of Lithium..

I have answers from 2 different resources;
0.8 to 1.2 mEq/L ................AND ...................
0.6 to 1.2 mEq/L with therapeutic dose = 300-2700 mg/d

Risk factors for specific cancers:

Bladder = Smoking, exposure to industrial, chemicals, radiation.
Prostate= African American and age 55 and older
Laryngeal = Smoking, uses of tobacco and alcohol, exposure to environmental
pollutants, exposure to radiation and carcinogens, nutritional deficiency
(riboflavin)
Lung = Smoking, exposure to environmental pollutant, vitamin A deficiency,
heredity.
Pancreatic= High fiber and high carb, smoking, exposure to industrial chemicals,
diabetes, chronic pancreatitis.
Breast = family history, early menarche and late menopause, previous cancer of
the breast, uterus, or ovaries, nulliparity, obesity, high-dose radiation exposure to
chest, diet high in fat, alcohol intake, the use of birth control pills and hormonal
replacement.

Endometrial= history of uterine polyps, nulliparity, polycystic ovary disease,

estrogen stimulation, late menopause, family history.
Ovarian= diet high in fat, family history of ovarian or breast cancer, alcohol use,
history of breast cancer, endometrium cancer, colon cancer, nulliparity, infertility,
Cervical= low socioeconomic, early first marriage, early and frequent intercourse,
multiple sex partners, poor hygiene, Human papillomavirus, HIV infection,
smoking during pregnancy and cervical infection.
Testes= over the age of 15 and 40, infection, genetic and endocrine factors,
cryptorchidism

PIH=Periorbital and facial edema

Pt. intubeted and a high alarm will sound when the patient is bitting the tube.
Halo traction=Sterile pin site care
T-12 spinal injury=No message to the bladder.
Thallium stress test=Allergic to Iodine should be asked
5 Post ops causes of fever
Wind-check lungs
Wound-Cl sirgoca; sote
Water-I V site
Walk-DVT check
Whiz-Catheter
Wonder drungs-drug fever
Measles warrents=resp isolation
Bacterial meningitis=Resp isolation
Methotrexate therapy=in 2 weeks expect to see signs of bone marrow depression
When pregnant increase your calories by 500 Kcals
Dystonia occurs after a few days of treatment of haldol
Heart failure infant=Increased resp rate
Trough level=lowest level of the drug should be done immediately before
administering the next dose
Glycosylated hemoglobin values less than or equal to 7.5% indicates good
diabetic control
Preterm infant before 37 weeks
Term infant older than 37 weeks
post erm 42 weeks
38-41 weeks is term
you should not insert a NG tube if there is a suspected skull fracture.
Deferoxamine is the antidote for iron poisoning
Cipro treats anthrax
Cretinism=Hypothyroidism found in the neonate
Nrdil (Pnenelazine) is a MAOI avoid figs, chocolate, and eggplant. It cause
hypertensive crisis.
Multiple sclerosis=test EEG/LP
A pregnant nurse should not be assigned to any client with radioactivity present.
OK for a Preg nurse to care for a client receiving liner ascelerator radiation
therapy for lung cancer.

Client with Cushing syndrome, with incresed level of cortisone cause the client to
be immune suppressed, Pt should be put in a private room.
complications of bucks traction=Weak peda pulses

1. To check for petechiae in a dark-skinned client, assess the oral mucosa

2. Seventh-Day Adventists are usually vegetarians

3. The three types of embolism are air, fat, and thrombus

4. Before discharge, a client who has had a total laryngectomy must be

able to perform tracheostomy care and suctioning and use alternative means of
communication.

5. The universal blood donor is O negative

6. The universal blood donor is AB positive

7. Mucus in a colostomy bag indicates that the colon is beginning to

function
8. Fatique is an adverse effect of radiation therapy.
9. celiac disease may eat rice
10. Dumping syndrome-limit liquids and high carbohydrate foods.

Addisons Disease: Hypo NA+, Hyoglycemia, Hypercalcemia

Hyperkalemia.... and the exact oppisite for Cushings syndrome!

Diabetes Insip... can concentrat urine!

Addisoinan Crisis is treated with High dose steriods and Fluid replacment
for treatment

and

In DKA (Diabetic Ketoacidosis),

---the arterial pH is lower than 7.35,

---plasma bicarbonate is lower than 15 mEq/L,
--- the blood glucose level is higher than 250 mg/dL,
---ketones (Acids created by the process of burning body fat; if the body
produces too many ketones, they are excreted in the urine) are present in the
blood and urine.
---The client would be experiencing polyuria, and Kussmaul's respirations would
be present.

---A comatose state may occur if DKA is not treated, but coma would not confirm
the diagnosis.

---Shakiness is a sign of hypoglycemia and would indicate the need for

food or glucose.
---A fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

During illness,
---the client should monitor blood glucose levels and should notify the physician if
the level is higher than 250 mg/dL.
--- Insulin should never be stopped. In fact, insulin may need to be increased
during times of illness.
---Doses should not be adjusted without the physician's advice and are usually
adjusted based on blood glucose levels.

Potassium chloride
--administered intravenously must always be diluted in IV fluid and infused via a
pump or controller.
--The usual concentration of IV potassium chloride is 20 to 40 mEq/L.
--Potassium chloride is never given by bolus (IV push). Giving potassium chloride
by IV push can result in cardiac arrest.
--Dilution in normal saline is recommended, but dextrose solution is avoided
because this type of solution increases intracellular potassium shifting.
--The IV bag containing the potassium chloride is always gently agitated before
hanging.
--The IV site is monitored closely because potassium chloride is irritating to the
veins and the risk of phlebitis exists.
--The nurse monitors urinary output during administration and contacts the
physician if the urinary output is less than 30 mL/hr.

After adding a medication to a bag of intravenous (IV) solution,

--the nurse should agitate or rotate the bag gently to mix the medication evenly in
the solution.
--The nurse should then attach a completed medication label.
--The nurse can then prime the tubing.


--Prednisone is a corticosteroid. With prolonged use, corticosteroids cause
adrenal atrophy, which reduces the ability of the body to withstand stress. When
stress is severe, corticosteroids are essential to life. Before and during surgery,
dosages may be increased temporarily.
--Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia.
--Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant.
--Conjugated estrogen (Premarin) is an estrogen used for hormone replacement
therapy in postmenopausal women.
***These other three medications may be withheld before surgery without undue
effects on the client.

Anticoagulants alter normal clotting factors and increase the risk of

bleeding after surgery.
--Aspirin has properties that can alter the clotting mechanism and should be
discontinued at least 48 hours before surgery.

Crohns Disease
Meds: Sedatives, antidiarrheals, antibiotics, steroids, antispasmodics and
analgesics
Hydration with IVF
High calorie, high-protein, low-residue diet

Crohns Disease
S/S:
Abdominal pain and cramping
Diarrhea
Weight loss
Fever
Anemia
Weakness and fatigue
Anorexia
--Abdominal Tendreness

Crohns Disease
Inflammatory disease affecting small bowels and
possibly large bowels characterized by
ulcerations in intestinal linings, scar tissue
formation causing narrowing and thickness in
bowels
Unknown cause
May lead to perforation, stricture and obstruction


Occult Blood Testing
Avoid red meats 3 days prior to test
May use stool specimen

SLE
Systemic Lupus Erythematosus
Nursing Interventions:
Emotional support in coping with prognosis
Alternative activity and planned rest periods
Avoid persons with infections, undue exposure to sunlight, and emotional
stress to prevent exacerbations
Diet: high in Iron : liver, shellfish, leafy vegies, enriched bread and cereals

Restraints
Release every 2 hours for med-surg restraints
and check every 1 hour for color movement and
sensation in the extremity involved
Requires order renewal every 24 hours
Siderails, medications are considered restraints

Sickle cell Anemia

Mgt:
Oxygenation
Hydration
Rest
Diet: High calorie High protein, increased fluids
Folic acid supplementation for anemia

Head lice
S/S: severe itching in affected areas; appearance of lice on hair or clothing
Tx: Kwell/lindane shampoo
Extra-fine-tooth comb
Wash all linens and clothing in hot water to destroy nits and eggs

Potassium Rich Diet

Fruits and fruit juices
Dried fruits/plums
Apricots
Bananas
Cantaloupe
Water melon

Open-angle VS Close-angle
Glaucoma

Open-angle- loss of peripheral vision, tunnel vison, difficulty adapting to the dark,
halos around
lights, difficulty focusing on near objects
Vague symptoms with client unaware of them for a time; visual acuity
deteriorates over time with increasing IOP
Close-angle glaucoma- triggered by pupil dilationhigh emotions and darkness;
S/s: severe eye and face pain, N&V, cplored halos around lights

Crutches
Use palms of the hands when crutch walking
Going upstairs: Good boys go to heaven
good leg goes first bad leg goes last
Suppository Administration
2 inches vaginally or rectally
Lube it!!!!
Nothing more nothing less
Cardiac diet
Low sodium
Low cholesterol
For heart failure: low sodium
For hypertension: low na, low fat
For MI: low Na, low fat
MEDS for Hyperthyroidism
Antithyroids:Methimazole (Tapazole)
Beta-blockers: Propranolol (Inderal)
Iodine: Lugols solution
Radiation: Radioactive Iodine 131
Iron Rich Foods
Red meats
Egg yolks
Leafy vegetables
Whole wheat breads
Legumes
Dried fruits
Potassium Rich Foods
Apricots
Avocado
Banana
Cantaloupe
Raw carrots

 Dried peas, beans, fruits

Melon, orange, orange juice
Peanuts, white/sweet potatoes
Prune juice, spinach
Tomatoes and tomato products, winter squash
Insulins
Peak hours:
Regular insulin- 2-4 hours
Insulin Aspart (Novolog)- 1-3 hours
Inslulin lispro (Humalog)- 1 hour
NPH/Humulin N- 6-12 hours
Insulin Zinc (Lente)- 8-12 hours
Ultralente- 18-24 hours
Insulin glargine- 5 hours
Humulin 70/30 4-8 hours
Appendicitis
Pain: located at McBurneys angle; right lower quadrant pain with rebound
tenderness
Elevated WBCs
Surgery stat
Preop: NPO, no enemas, no pain medications,no heat applications just cold
packs, IVFs, check lytes; Semi Fowlers right side-lying to localize infection
Postop: immediate ambulation in 6-8 hours
Hypoglycemia

Always a priority!!!!
Can cause brain damage
Manage according to facility protocol
Glucose tabs, Orange/apple juice if awake
Dextrose 50% 1/2 amp to 1 ampule IV
Glucagon shot
Dextrose 10% IV infusion

Hearing Impaired

DO not touch patient until they are aware youre in the room

Speak to the face

Articulate clearly but not too slowly
Move close to patient; do not cover mouth with hands
Provide alternate methods of communicating: Magic Slate, Sign

A mother is concerned of a breastfed baby about gaining too much weight!

With

adequate output (DIAPER COUNT) in infants this ensures adequacy of

nutritional intake

Which should a nurse see first among these clients in active labor?
Gravida

1 para 0 with bulging of membranes

Gravida 2 1 cm dilated
Para 4, 1 cm dilated with history of C-section
Para 5, 2cm dilated

Answer
Para 4 with hx of c section takes priority in order monitor and prevent the
occurrence of uterine rupture.

Which one of these patient assignment for a travel nurse should be

reassigned?
HIV client
Client with contagious disease
Client who just developed a rash
Patient with green purulent sputum
Answer: Client with RASH as this requires

Verbal Orders
Which of these medications need a specific written

order from aprescribing

physician?
Insulin
Digoxin
Coumadin
Chemotherapeutic agents
Answer: Chemotherapeutic agents as this requires also double checking with a
chemo certified RN. A chemo certification is required for administration of chemo

agents

Are you planning to kill yourself?

A client who is terminally ill says to the nurse, This is too much for me. You have
been very good to me so I will give you my watch. The nurses response should
be:
a. Give it to your family.
b. Keep it.
c. Are you planning to kill yourself?
d. Dont worry.

Closed Liver Biopsy

PRE:

NPO 4-6 hours

Consent
Reinforce teaching about procedure
Baseline VS, bleeding parameter
Empty bladder
Supine position on far right side

Liver Biopsy
DURING:

Hold breath after exhalation to keep diaphragm and liver high in abdominal cavity
during insertion
Needle insertion between the 6th-7th ICS
10 -15 seconds to obtain tissue

Liver Biopsy
AFTER:

Apply direct pressure right after needle removal

Right side lying position
Vitals to check for bleeding
NPO for 2 more hours
No coughing, lifting, or straining for 1-2 weeks

Myxedema

 Adult

form of hypothyroid crisis

Characterized by mental sluggishness, drowsiness, lethargy progressing to coma;

Hypotension

Which among these patients

need a private room?
HIV

patient

Client awaiting renal transplant

Hepatitis
Scabies
Answer: Scabies is caused by sarcoptes scabei leading to skin infestation.
Female mite burrows in areas between fingers and toes and warm folds of the body
such as axilla, groin, to lay eggs.

Scabies
S/S:
Burrows - visible dark lines
Mite - seen as black dot at end of burrow
Severe itching
Scratching with resulting secondary infection

Scabies Treatment
Permethrin

Cream (Elimite)

Lindane lotion
Scrub body with soap and water then apply lotion on all areas except the face
Leave permethrin on the skin for 8-12 hours and then wash off completely with
warm water
All who had close contact with person within 30-60 day period should be treated

Removing Gown, Glove, Mask

1. Remove gloves
2. Remove mask
3. Untie gown
4. Wash hands

5. Remove gown
6. Fold it inside out and discard
7. Wash hands again

CHVOSTEKS SIGN
Sign

of hypocalcemia

Characterized by twitching when tapped on the facial muscle

hypoparathyroidism

TB Test
Positive skin test (Mantoux test)- 10 mm
induration; not redness/erythema
Indicates exposure to bacilli
Confirmatory:
Chest X-ray, 3 (+) sputum AFB

Universal Precautions
Everybody is infected
Body, body fluids, secretions, excretions,
Mask, eye shields, gloves, gown
Hand hygiene

Myocardial Infarction (MI)

Immediate treatment: MONA
Morphine,
Oxygen,
Nitroglycerine,
ASA

Hypoxia

 Early signs: REMEMBER (RAT)

Restlessness, Anxiety,Tachycardia / Tachypnea

Late signs: REMEMBER (BED)

Bradycardia, Extreme restlessness, Dyspnea (severe)
Iron Administration
REMEMBER:
Iron supplements IM or IV----iron dextran (IV route is preferred)
IM causes pain, skin staining, higher incidence of anaphylaxis
Take oral supplements with meals if experience GI upset
Then resume between meals for max absorption
Use straw if liquids are used

Depression & Suicidal

Depression and signs and symptoms
of suicide: watch for suicidal ideation.
Suicide alert: when depressed mood
begins to lift and/or energy level increase.

INH
Prevent and treat TB
Remember when taking INH
Do not drink alcohol
Take vitamin B6 to prevent peripheral
neuropathy
Take with food if not tolerated on an empty
stomach
Do not get pregnant

Growth & Development

Birth weight doubles in 6 months
Pre-schooler - has imaginary friends

 Infant gains head control by 4 months

Posterior fontanel closes at 2-3 months
Anterior fontanel closes by 12-18 months

Tension Pneumo
*trachea deviate to opposite side ( I remember it like OPopposite=pneumo, same=atelectasis.) hypotension and bradycardia.
Albuterol
*tachycardia, nervousness, insomnia, anxiety.
Hip fracture
*Fractured leg shorter, externally rotated, adducted.
Radiation
*Stomatsis(irriation of mucous membrane), Xerostomia(dry
mouth) and dysgeuia(decreased taste)
*protrusion of ileal conduit=stoma prolapse.
*Take nystatin after meals.
*lower lung sounds-vesicular close to trachea(but not directly
over)=bronchial
*Multiple mylomas=increased immunloglobins expected.

Disaster planning
A disaster plan needs to be activated when there is a life
threatening situation with a large number of patients involve. A
way to remember who to remove first is by using ABC
A- Ambulatory
B- Bed Ridden
C- Critical Care
You may ask why but the goal is to move the greatest number of

clients.
Appendicitis- position of comfort is on the side with the legs
flexed agains the abdomen. HOB should remain slightly elevated
to decrease the upward spread of infection in case the rupturing
of appendix occurs.

Activated charcoal - To absorb poison

AAA- Complication is hemorrhage and shock
A positive mantoux test indicate the pt has produced an immune
response
Complication of warfarin- (3H) hemorrhage, hematuria and hepatitis
Colchine for treatment of gout attack
Codeine- onset- 30mins, peak- 1hr, duration 4-6hrs
COPD -use of acessory muscle for respiration indicate the pt is having
difficulty breathing
Chlamydia, Genital herpes and HPV - Do not report
Crackles are heard on inspiration and dont clear with cough
Diaphramatic and purse lip breathing are the best for pt with COPD
DMD- X-linked recessive and female are carrier and male are affected.
DI- Treatment is DDAVP
Gastric lavage - To remove poison
Indomethacin - helps in closing PDA
Left sided HF- pulmonary
Myelomingocele complication - clubbfoot and hydrocephalus
Meningitis- Droplet
Osteoarthritis- Joint pain, crepitus, heberden's node, bouchard's node

and enlarge joints

Pentoxifyline- hemorheologic Agent that improve blood flow and is
used to treat intermittent claudication
Prostaglandin E is administerd to provide blood ming and also help to
keep open the ductus arteriosus
Right side HF- systemic
Rhonchi are heard on expiration and clear with cough
Rabies- contact precaution
tPA- used to treat Acute MI
Thrombolytic- dissolve clots
To avoid falsely elevated serum digoxin, the nurse should wait @ least
8hrs after administering oral digoxin and @ least 6hrs after
administering I.V digoxin to draw a blood sample.
TB- airborne

Breast Cancer Risk Factors:

>50 years of age
FIRST child born after 30 years of age
Grandmother, Mother, Sister has it
Personal history of breast cancer

Garlic has a hypoglycemic effect do not give with insulin

Eye problems do not want head in dependent position. Lie on good
side and have bad eye upor elevate the head of the bed to 35
degrees.
Lay on right side after liver biopsy.
Clear fluid from head CSF medical emergency call the doctor
1 yr old with nausea, vomiting, and diarrhea is emergency because
young children become dehydrated very easily

Assess pt for claustrophobia with CAT scans and MRIs, also, NO

METAL.
Cheyenne stokes- "Dead man breathing" Tachypnea with periods of
apnea.

Kussmauls breathing- Deep and Fast, seen in pts experiencing

Hyperglycemia also look for Fruity Breath.
The diabetes that isn't really a diabetes:
Diabetes Insipidus- Named diabetes b/c of the diuresis it causes
similar to that which a person with diabetes would experience.
The polyuria is caused by a deficiency of the ADH(Anti-diuretic
hormone) causing the patient to excrete alot of urine. Check for Low
Specific gravity, hypernatremia, Serum Osmolality may be low for . Pt
will have to urinate frequency, have extreme thirst and may easily
become dehydrated. Unlike SIADH (syndrome of inappropriate ADH)
you want to increase fluid intake to hydrate the patient.

SIADH- Syndrome of Inappropriate ADH or as I like to think of it

"Syndrome of IncreasedADH". Common in patients with a damaged
CNS (Central Nervous System). Excessive ADH is released from the
Pituitary gland resulting in hyponatremia, concentrated urine and fluid
overload.
NSAIDS like Ibuprophen (Motrin) can cause GI bleeds, never take on
an Empty stomach. Think"NSAIDS take with BREAD"
No milk served with meat- Jews
Clients with physical disabilities frequently respond good to support
groups
Dos and Donts
Dont
Dont
Dont
Dont

pass buck
provide false Reassurance
ask why
treat psychosocial first

Do ask patient to express themselves, their concerns

INH can cause liver problems so stay away from alcohol
Risk Factors for Pneumonia Old age, bed ridden, post op, pre existing
lung problems
Cane walking- Hold the cane in hand opposite of weak leg and move
with weak leg. I.E. with weak right leg, advance left hand (cane)
followed by right leg then left leg.
Lying prone prevents flexion contracture of hip
Poor Potassium values Call Physician. Cardiac Emergency!

Pavlik harness- is a harness applied to young children with hip

dysplasia. it goes around their mid section and over their shoulders in
the front looking like a pair of suspenders. It then makes and x in the
back and connects to the child's feet and ankles in the front and back.
The child should wear knee high socks and a under shirt to prevent
skin break down. Massage the skin under the straps daily (w/out
lotions, ointments) SEE HERE
JVD (jugular vein distention) is a symptom of a cardiac tamponade,
a complication of CABGs caused by blood accumulating around the
heart in the pericardial sac and compressing the myocardium,
atrium, and ventricles.

IF you have a female patient undergoing Peritoneal Dialysis and the

output is bloody you need to determine if she is menstruating. The
reason being, the dialysate is so concentrated to pull fluid from the
abdominal cavity that the hypertonicity may cause blood to be pulled
from the uterus through the fallopian tubes and into the effluent.
Here are a few facts:
Use FIRST to help you remember
F- find hypoxia
I- Immunocompromised
R- Real bleeding ( Trauma, hemorrhage)
S-Safety
T- Try infection
For Cardiac
It use to be MOAN but the American heart Association has changed it
Now it is ONAM
O- Oxygen
N-Nitoglycerine
A- Asprin

M- Morphine
-----Prostate cancer
most frequently diagnosed cancer in men. reasons unclear
second-leading cause of cancer death in men.
chemoprevention: finasteride and dutasteride

Substance Poisoning and Antidotes

Methanol =>ethanol
carbon monooxide=>Oxygen
Dopamine=>Phentolamine
Benzo=>flumazenil
Lead=>Succimer
Iron=>Deferoxamine

INTERVENTIONS FOR COPD (using ABCDEF)

A-Aminophylline
B-Brochodilators
C- Chest Physiotherapy
CORTICOSTEROIDS
D- Deliver oxygen at 2 liters
E- Expectorants
F- Force Fluids
Tuberculosis ( Meds) Use RISE
R-Rifampin
I-Isoniazid (INH)
S-Streptomycin
E-Ethambutol
Care of Client After Masectomy
(BREAST)
B-Bp not on affected side
R- Reach recovery
E-Elevate affected side
Exension and flexion exercise- initialy (Squeeze a ball)
A-Abduction and external rotation should not be initial exercise
S-SBE- Once a month- about one week after period
T-To promote a positive self image
TURPS
T-Tubes
U-Urinary output
R- Red drainage
P-Pieces of clots
S-Spasms

Meniere's Disease
Administer diuretics to decrease endolymph in the cochlea, restrict
sodium, lay on affected ear when in bed.
TRIAD
-vertigo
-Tinnitus
-Nausea and vomiting.

pheochromocytoma: neuroendocrine tumor of the medulla of the

adrenal glands. This causes and increased secretion
of catecholamines (epinephrine, and norepinephrine) Signs and
Symptoms same as body's Sympathetic Nervous System Response:
>Elevated HR
>Elevated BP
>Palpitations
>Anxiety
>Diaphoresis
>Headaches
>Pallor
>Wt. Loss
>Elevated Blood Glucose Level (due to catecholamine stimulation of
lipolysis) Tetany tests:
Chovstek's sign- Tap facial nerve 2 cm anterior to earlobe just below
zygomatic arch. Twitching of facial muscles indicates tetany.
Trousseau's sign- Inflate BP cuff to 20mmHg above Systolic. Carpal
spasms w/in 2-5 mins indicates tetany.

Rheumatic Fever Signs and Symptoms

Rheumatic fever is a complication of untreated strep throat, caused by bacteria called
Group A Streptococcus. It is potentially life threatening. Since one of the main
symptoms of rheumatic fever is pain in the joints, use the word, JOINTS to remember
the signs and symptoms.
J- Joints are painful
O- Over a long period it can damage the heart
I- Infection may be too mild to be recognized
N- Nervous system can be affected leading to chorea
T- Throat that is sore
S- Swollen joints

Memory aid for signs of potential problems for Oral

Contraceptives = ACHES
A - Abdominal pain (possible liver/ gallbladder issue)
C- Chest pain or SOB (possibility of pulmonary embolus)
H - Headache (possibility of hypertension / brain attack)

E - Eye problem (possibile hypertension / vascular attack)

S - Severe leg pain (possible thromboembolic process)
Cleft Lip: nursing care plan (post OP) = CLEFT2 LIP
Crying = minimize
Logan bow
Elbow restraints
Feed w/ Brecht feeder
Teach feeding techniques; average age for repair is TWO months.
Liquid (sterile water)/ rinse after feeding
Impaired feeding (no sucking)
Position - never on abdomen
KAWASAKI DISEASE:
Unknown cause
Early tx with Gamma globulin to reduce cardio damage.
Abrupt onset of fever (102-106 F) lasting more than 5 days that get
no better with antibiotics/antipyretics.
Conjunctivitis, bilateral and nonpurulent.
Peeling of the palms of the hands and feet.
Generalized rash on trunk and extremeties, w/o crusts or vesicles.

Lab tests results for KAWASAKI DISEASE = elevated ESR, WBC &
Platelet count.
Screening tests.
-women should pay attention to their breast at the age of 20,this is
the time when females should start perform self breast
examination,once a month 7 days after their menstrual period
beggins,they dont have to have a mammograph yet however it is
recommended that women between ages 20-29 should have a
professional physical examination of breast every three years.
-women who are 40 and over should have a mammograph plus
physical breast examination done every year.
-the first pap smear should be performed at the onset of sexual
relations and done annually after a woman reaches the age of 18.
-men who turn 50 (or man who are 40 with a risk factors) should have
a prostate specific antigen test done annually for prostate cancer.
-men who turn 40 should have a rectal digital exam done yearly to
screen for colon cancer.
-men who turn 50 should have a a guiac test for occult blood done
annually (to screen for colon cancer)
-men who turn 50 should have a proctoscopy done every 3 to 5 years
to screen for a colon cancer.
-people especially men when they turn 45 and have a normal
cholesterol level should have this test done every five years.
-men (especially adolescent men) should perform self-testicular exam
every month after a warm shower.

-all the people above the age of 21 should have their blood pressure
checked.
When drawing two different insulins Cloudy CLEAR CLEAR Cloudy
Air in cloudy air in clear, draw clear draw cloudy
Antidote for Coumadin- Vitamin K
Antidote for Heparin- Protamine Sulfate

Advantageous Crisis= from an external source

Examples:
a) earthquake
b) flood
c) any natural disaster
Maturational Crisis= related to rites of passage
Examples:
a) retirement
b) birth of a child
c) kids going to college, moving out---empty nest
d) marriage

NCLEX QUESTIONS
1. When does birth length double - By 4 years
2. When does child sit unsupported - By 8 months
3. When does a child achieve 50% of adult height - 2 years
4. When does a child throw a ball overhand - 2 years
5. When does a child speak 2-3 word sentences - 2 years
6. When does a child use scissors - 4 years
7. When can a child tie his/her shoes - 5 years
8. Girls growth spurt during adolescence begins earlier than boys. May begin as
early as 10 years old.
9. Temper tantrums are common in the toddler; they are considered normal or
average behavior.
10. Adolescence is a time when the child forms his/her identity and that
rebellion against family values is common for this age group.
GROWTH AND DEVELOPMENT FOR PEDIATRICS
PEDIATRICS
1. Motor skills progress in a proximal to distal manner.

2. NEONATE (Birth to 28 days):

A. Vital signs:
1. Pulse: 110 - 160 BPM count apical for one minute
2. Respiratory rate: 32 - 60 BPM. Neonate is an obligate nose breather.
3. Blood pressure: 82/46.
4. Temperature regulation is altered because of poorly developed sweating
and shivering mechanisms.
A. Limit exposure time during baths.
B. When the neonate is wet or cold cover his head.
5. Mortality rate is higher in the neonatal period than in any other growth
stage.
B. Head and chest circumference are relatively equal. Head circumference
may be up to greater than the chest circumference.
C. Head length is one-fourth total body length.
D. Brain growth depends on myelinization.
E. All behavior is under reflex control. Extremities are flexed.
1. Moro reflex- Elicited by striking a flat surface the infant is lying on. The
reflex of abducting extremities and fanning fingers when a sound is heard
should be gone by 3-4 months. Strongest at 2 months
2. Rooting - When the cheek of the newborn is stroked, the newborn will
turn his head in the direction of the stroke. Usually disappears 3-4 months
3. Tonic neck - While the newborn lies supine, his head is turned causing the
extremities on the same side to straighten and those on the opposite side to
flex (fencing posture). Disappears at 3-4 months.
4. Babinski - When the sole of the foot on the side of the newborn small toe
is stroked upward, the toes will fan upward and out
5. Plantar grasp - Infants toes will curl downward when sole of foot is
touched.
6. Startle - A loud noise such as a hand clap will elicit the newborn to abduct
his arms and flex his elbows. Best elicited after infant is at least 24 hours
old and disappears within 4 months.
7. Palmar/plantar grasp - Place a finger in the palm of the newborns hand
and then place a finger at the base of the toes, the newborns fingers and
toes curl downward.
F. Hearing and touch are well developed; a hearing screening is
recommended.
G. The neonate is stimulated by being held or rocked; listening to music and
watching a black-white mobile.

H. While laying prone, the neonate can lift his head.

3. INFANCY: Age 1 month to 1 year.
A. Period of rapid growth in which the head, especially the brain, grows
faster than other tissues.
B. According to Erickson, the infant is in the critical stage of Trust vs.
mistrust. It is important for the child to develop a trusting relationship with
a consistent primary caregiver. Interference may cause failure the thrive.
C. Birth weight doubles in 6 months.
D. Birth weight triples in one year.
E. Posterior fontanel closes by 2-3 months.
F. Anterior fontanel remains open until 18 months.
G. Height increases by 50% in 1 year.
H. Head circumference > than chest circumference until 1 year.
I. Tooth eruption starts at 4 months -> 1 tooth per month.
J. AGES 1 TO 4 MONTHS
1. Instinctual smile appears at age 3 months. The social smile is the infants
first social response. The social smile initiates social relationships, indicates
memory traces, and signals the beginning of thought processes.
2. The infant develops binocular vision; the eyes can follow an object 180
degrees and any intermittent strabismus should be resolved by age 4
months.
3. The infant reaches out voluntarily but uncoordinatedly.
4. At age 4 months the infant laughs in response to environment.
5. Recognizes parents voices.
6. Explores his feet.
7. Appropriate toys: Music box, mobile, mirror.
K. AGES 5-6 MONTHS
1. Birth weight doubles.
2. Can sleep through the night with 1-2 naps a day.
3. Lower central incisors appear first. Results in ed drooling and irritability.
4. Rolls over from stomach to back.
5. Infant cries when parents leave - a normal sign of attachment. Exhibits
stranger anxiety.
6. Can transfer toys from one hand to another
7. Exhibits comforting habits - sucks thumb, rubs his ears, holds a blanket
or stuffed toy.
A. All these symbolize parents and security.
B. Thumb sucking in infancy doesnt result in malocclusion of permanent

teeth.
8. Appropriate toys: Bright toys, soft toys, rattle - THINK SAFETY.
L. AGES 7 - 9 MONTHS
1. Sits alone without assistance
2. Creeps on his hands and knees with his belly off of the floor.
3. Infant stands and stays up by grasping for support.
4. Develops a pincer grasp; places everything in his mouth - ed risk of
aspiration.
5. Self-feeds crackers; the infant whos physically and emotionally ready can
begin to be weaned to a cup.
6. Likes to look at self in mirror.
7. Develops object permanence and searches for objects outside his
perceptual field.
8. Understands the word NO; discipline can begin. Cries when reprimanded.
9. Can verbalize consonants but speaks no intelligible words. 10. Appropriate
toys: Peek-a-boo, cloth toys.
M. AGES 10 - 12 MONTHS
1. Birth weight triples and birth length increases about 50%.
2. Imitative behaviors.
3. Infant cruises (takes steps while holding on) at age 10 months, walks with
support at 11 months, and stands alone and takes his first steps at 12
months.
4. Infant claps his hands, waves bye-bye and enjoys rhythm games.
5. Enjoys books and toys to build with and knock over.
6. Cooperates when dressed.
7. Can say Mama/dada and two syllable words.
8. Shows jealousy.
9. Infant explores everything by feeling, pushing, turning, pulling, biting,
smelling, and testing for sound.
10. Appropriate toys: Push toys, large ball, large blocks.
N. NUTRITION
1. Introduce foods in this sequence
A. Breast milk or iron-fortified formula: According to AAP (American
Academy of Pediatrics) they recommend breast feeding exclusively for the
first 4-6 months of life and then in combination with infant foods until age 1.
1. Give breast fed infants iron supplements after age 4 months because iron
received before birth is depleted.
2. Breast milk is a rich source of linoleum acid (essential fatty acid) and

cholesterol which are needed for brain development.

3. Contains immune factors that protect infants from infection.
B. Dont give solid foods for the first 6 months
1. Before age 6 months, the GI tract tolerates solid food poorly.
2. Because of strong extrusion reflex, the infant pushes food out of his
mouth.
3. The risk of food allergy development may increase.
C. Provide rice cereal as the first solid food followed by any other cereal
except wheat.
D. Give yellow or green vegetables next.
E. Provide no citrus fruits followed by citrus fruits after age 6 months.
F. Give infants teething biscuits during teething period.
G. Provide food with sufficient protein such as meat, after age 6 months.
H. After 12 months, switch from formula to regular WHOLE milk.
1. Dont give skim milk because fatty acids are needed for myelinization.
2. Whole milk should be continued until age 2 as recommended by the AAP.
I. RULES FOR FEEDING
1. Dont prop up baby bottle - s risk of aspiration & ear infections.
2. Dont put food or cereal in a baby bottle.
3. Introduce one new food at a time; wait 4-7 days before introducing new
food to determine infants tolerance to it and the potential for allergy.
SAFETY GUIDELINES
1. Place infants supine for sleep to decrease the risk of sudden infant death
syndrome.
2. Keep crib rails up at all times, keep away from windows and curtain cords.
Crib slats should not be more than 2 apart with mattress firmly against its
rails to prevent infant falling in-between mattress and slats.
3. Use car seats properly - keep infant placed facing back of back seat.
4. Never leave infant unattended on dressing table or any other high place.
5. Dont warm formula or breast milk in microwave. Defrosting in microwave
may destroy its immune factors. Formula/food should be lukewarm.
6. Insert safety plugs in wall outlets
7. Use gates along stairways.
8. Keep soft objects and loose bedding out of the crib. Pillows, quilts,
sheepskins and comforters should be kept out of infants sleeping
environment.
9. Avoid overheating; infant should be lightly clothed for sleep.

10. ALWAYS support infants head.

11. Check temperature of bath water - should be 90-100 degrees.
P. TODDLER (Ages 1 to 3)
1. Vital signs: Pulse 100 BPM
Respiratory rate: 26 BPM
Blood pressure: 99/64
2. Period of slow growth with a weight gain of 4-6 lbs per year. Normally
weighs four times birth weight.
3. Anterior fontanel closes between ages 12 and 18 months.
4. The toddler is egocentric.
5. Follows parents wherever they go.
A. Start playing peek-a-boo to develop trust.
B. Progress to playing hide and seek to reinforce the idea that his parents
will return.
6. Separation anxiety arises.
A. The toddler sees bedtime as desertion.
B. Develops a fear of the dark. Nightmares begin around 2-3.
C. Separation anxiety demonstrates closeness between the toddler & his
parents.
D. The parent who is leaving should say so and should promise to return.
1. Parent should leave a personal item with the toddler.
2. Prepare the parents for the toddlers reaction, and explain that this
process promotes trust.
E. According to Erickson, this is the critical stage of AUTONOMY (self
control & will power) VS SHAME. The child develops a sense of independence
and should be allowed to explore the environment with the encouragement of
the primary caregiver. Temper tantrums, negativism, and disciplinary
problems are the hallmarks of this age group as the child learns to control
his environment and express his will. The child should be taught to tolerate
frustration through socialization and proper toilet training.
1. According to Freud, toddlers are egocentric and possessive and struggle
with holding on and letting go behaviors (ANAL STAGE).
2. Toddlers usually begin to imitate sex role behavior.
3. Piaget: Sensorimotor stage the child enters the pre-operational stage in
which he begins using a trial and error method of thinking and reasoning.
F. The toddler may engage in solitary play and have little interaction with
others, this progresses to parallel play (toddler plays along-side but not with
other children.

G. To promote development of autonomy, allow the toddler to perform tasks

independently and provide choices.
H. Toddler understands object permanence.
I. Discipline during this stage should be a demonstration of love, not anger.
The toddler needs limits set on unacceptable demands, such limits offer
security. He should be praised liberally, but only when deserved.
J. Things to expect:
1. Sphincter control begins at age 2.
2. All deciduous teeth erupt by 21 months - 2 years.
3. Pot-bellied appearance.
K. 18 months
1. Is in the MY stage. 2. Vocabulary of 25 words.
3. Walks independently 4. Can use a spoon.
5. Climbs.
Appropriate toys: Push/pull toys, blocks.
L. 24 months
1. Negativistic 2. Temper tantrums
3. Transitional object 4. 2-4 word sentences, 400 words
5. Walks up/down stairs 6. Turns door knobs
7. Builds tower of 6 blocks 8. Removes clothes
9. Appropriate play: Parallel play, sand, riding toys, water play, finger paints.
10. Manage temper tantrums: Ignore behavior, monitor for safety.
11. Toddler uses NO excessively and shows assertiveness. Is curious how
parents will react to use of NO.
12. Overcriticizing and restricting the toddler may dampen his enthusiasm
and increase shame and doubt.
13. Total sleep required is 12-14 hours. Sleep problems are common.
14. Toilet training
A. Consider emotional readiness
B. The toddler acts to please others, trusts enough to give up his body
products, and begins autonomous behavior
C. Parents must be committed to establishing a toileting pattern and must
communicate well with the toddler.
D. Offer PRAISE for success - NEVER punishment for any failure.
E. Dont refer to bowel movements as being dirty or yucky. Excrement is
the toddlers first creation.
F. Introduce underpants as a badge of success and maturity.
G. Most toddlers achieve day dryness by age 18 months to 3 years and night

dryness by ages 2-5. NEVER punish for ACCIDENTS. If toddler is not

trained by age 5, seek further evaluation.
H. Toddler may fear being sucked into the toilet.
I. Teach proper wiping technique (front to back) and hand washing.
J. Toilet Training - when kid can communicate need to go (non verbal or
verbal), holds on to please mom and doesn't let go to please self, sphincter
control 18 months - 24 months (myelination of the cord is complete now),
motor skill. Ability to stay dry for 2 hours, can sit still on toilet for 5 - 10
minutes without fussing, curiosity about older people's habits. No right or
wrong time !
15. When the toddler starts climbing over the crib rails, switch to a bed.
16. Use locks on cabinets, keep handles away from edges of tables or stoves.
17. AVOID bean bag toys.
18. Appropriate toys: Nested toys, toys with parts that open and close. Toys
designed for pounding such as play hammers and drums. Toy telephones,
dolls. Provide the child with opportunities for positive imitative play. They
enjoy simple songs with repetitive rhymes as well as moving in time to music.
A musical activity should be scheduled into each day.
19. NUTRITION:
A. Toddler feeds himself, provide finger foods in small portions
B. Because of increased risk of aspiration avoid foods such as hot dogs,
grapes, nuts and candy (or cut into small pieces).
C. Nutritional needs decrease because of slow growth period.
D. Child may become a picky eater. Nutritional content of food is important.
E. The toddler shouldnt drink more than 24 ounces of milk a day in order to
have room for other nutritious food.

MILESTONES
By Age 3:
Able to jump in place Able to kick a ball
Able to ride a tricycle Able to state name, age, and gender
Able to copy a cross and circle Most speech is understandable by others
By Age 4:
Able to sing simple songs Able to draw a person with 3 or more body parts
Able to distinguish between reality and fantasy
Able to state first and last name
Able to build tower with at least 10 blocks

Able to hop on one foot at least 3 times

Able to throw ball over handed All speech is understandable
By Age 5: (Enters Kindergarten)
Able to dress self without assistance
Able to state entire name (first, middle, and last)
Able to state home address and home phone number
Able to follow 2-3 step directions
Able to count to 10 on fingers
Able to copy a triangle or square
Able to draw a person with head, body, and all extremities
Able to recognize most letters of the ABCs and able to print a few
Plays make believe
By Age 6:
Able to walk heel/tow forward and backwards
Able to hop on either foot
Able to catch baseball size ball with 2 hands
Able to feed self correctly using knife, fork, and spoon
Able to cut out simple shapes with scissors
Able to distinguish between right and left hand
Able to play games involving matching skills
Able to repeat simples nursery rhymes
Able to choose peers for play
Is protective of younger siblings